New Client Registration Form Client Information "*" indicates required fields Owner/ Client Profile SectionName* First Name Last Name Phone*Alternate PhoneEmail Address* Email Reminders Yes No Address* Postal Code* Untitled Add Additional Owner Name* First Name Last Name Phone*Pet / Patient Profile SectionPatient Name* Sex*SelectNeutered MaleMaleSpayed FemaleFemaleUnknownAge or Date of Birth* Species* Breed/Morph/Color add Add Pet 2 Patient Name* Sex*SelectNeutered MaleMaleSpayed FemaleFemaleUnknownAge or Date of Birth* Species* Breed/Morph/Color add1 Add Pet 3 Patient Name* Sex*SelectNeutered MaleMaleSpayed FemaleFemaleUnknownAge or Date of Birth* Species* Breed/Morph/Color add2 Add Pet 4 Patient Name* Sex*SelectNeutered MaleMaleSpayed FemaleFemaleUnknownAge or Date of Birth* Species* Breed/Morph/Color add3 Add Pet 5 Patient Name* Sex*SelectNeutered MaleMaleSpayed FemaleFemaleUnknownAge or Date of Birth* Species* Breed/Morph/Color add4 Add Pet 6 Patient Name* Sex*SelectNeutered MaleMaleSpayed FemaleFemaleUnknownAge or Date of Birth* Species* Breed/Morph/Color add5 Add Pet 7 Patient Name* SexSelectNeutered MaleMaleSpayed FemaleFemaleUnknownAge or Date of Birth* Species* Breed/Morph/Color Anything Additional You Would Like Us to Know about Your Pet/Pets?Have you booked your appointment? If so, when?Terms of Service* By submitting this form I do accept the Terms of Service.Payment in full is required at the time services are rendered. We do not offer any form of billing or payment plans. If you have any financial concerns, please ask us about PetCard or Healthsmart financing options. We accept Cash, Debit, VISA, and MasterCard as forms of payment. We’re committed to protecting your privacy and therefore have safeguards in place to protect your personal information. We review our policies regarding client confidentiality and ensure that your personal information is protected against loss, theft, unauthorized access, disclosure, copying, use or modification regardless of the format it is in. We collect and keep information about you, which we require to provide products and services to you at your request. We collect this information from you, either directly or through other sources such as previous veterinarians, family members, veterinary team members, other health care providers, third parties such as financial institutions or pet care insurance companies, or regulatory bodies. We may also notify you of new products and services available, upcoming events, appointment notices or to communicate with third parties such as other veterinary hospitals when it is in relation to the services that we provide to you. All information I have provided here is true to the best of my knowledge. I certify that I am over the age of 18 and I have read and understand the Terms of Service.CommentsThis field is for validation purposes and should be left unchanged.
